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each of these techniques and were generally dissatisfied with the size of the gastric pouch which we tended to make larger than an ideal size because of our concerns about either stapling the stomach around the anvil or because we planned to make a gastrotomy for anvil insertion in the gastric pouch.

In addition to this technique being awkward it requires dilatation of the abdominal wall to insert the circular stapler as described above. Furthermore, postoperative pain following this port site dilatation maneuver may prolong hospital stay in some patients following surgery. As reported by others, we also noted higher wound infection rate at this port site skin incision likely resulting from bringing the tissue donuts through this wound when the stapler was removed. Some authors have recommend a mechanical and antibiotic bowel prep before surgery to decrease the risk of wound infection. The concerns of postoperative pain and wound infections do not seem related to the method of anvil placement but rather to the concept of using a circular stapling device to create the anastomosis no matter how the anvil was delivered into the gastric pouch.

Linear Stapled GastrojejunalAnastomosis

This technique was developed by Champion although, some surgeons have utilized this technique for the gastrojejunal anastomosis during open bypass surgery. In our early experience with this technique, we placed two holding sutures with the Endo-stitch followed by creating 1 cm openings in the Roux and in the gastric pouch with the ultrasonic dissector for the the linear stapler (Endo-GIA II, Tyco/ USSurgical, Norwalk, CT) to be inserted approximately 2.5 cm to create a side-to-side gastroenterostomy. The anastomosis was then stented with an appropriately small (10-12 mm, 30 or 32 F) diameter dilator passed via the mouth by the anesthesiologist. In a number of cases, we used a subsequent firing of the linear stapler to close the anterior opening in the anastomosis over the internal stent. Experience with this technique was unsatisfactory for two reasons: 1) the intraoperative leaks during air insufflation via the endoscope were unacceptably high (20%) frequency of cases and 2) sometimes it was difficult to pass the scope through the anastomosis because of narrowing along the long closure staple line. As a result of these concerns, we began to oversew the entire anastomosis to prevent the need for intraoperative leak repair. Currently, we begin by running a non-absorbable (2-0 Surgidac® on the Endo-stitch®, Tyco/USSurgical, Norwalk, CT) 9-inch length suture between the Roux limb and the posterior gastric pouch for a distance of approximately 3 cm to serve as a posterior suture row for a 2-layer anastomosis (Fig. 10.27). The stapler is then used to create an 'inner row' of the anastomosis posteriorly (Figs. 10.28 and 10.29). We have found that a 45 mm length cartridge of 3.5 mm staples provides adequate staple height for the thickness of the tissue and is hemostatic for this inner row. Using a shorter cartridge length, e.g., 30 mm, is not desirable as the stapler itself may not be long enough to reach the appropriate location due to the patient's obesity.

Rather than an esophageal dilator, we routinely guide the flexible gastroscope down the esophagus and across the anastomosis without insufflation of air to avoid bowel distension during the procedure, leaving it in position for subsequent insufflation of the bowel lumen to visualize and test the integrity of the surgical anastomosis. This saves time, as it can be difficult to pass the scope into the gastric pouch from above and immediately find the completed gastroenterostomy due to

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